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AtlantiCare Health Services Mission Health Care
AtlantiCare Health Services Mission Health Care
Region II Conference
Integration of Behavioral Health in Primary Care
June 2, 2010
Region II Conference
Integration of Behavioral Health in Primary Care
June 2, 2010
What is Primary Health Care?What is Primary Health Care?
• “Essential health care”
• Universally accessible to individuals and families
• In a community
• Provided as close as possible to where people live and work
• Care based on the needs of the population
• “Essential health care”
• Universally accessible to individuals and families
• In a community
• Provided as close as possible to where people live and work
• Care based on the needs of the population
Providing behavioral health in primary care involvesProviding behavioral health in primary care involves
• Diagnosing and treating people with mental disorders
• Putting in place strategies to prevent mental disorders
• Ensuring that primary health care workers are able to apply key psychosocial and behavioral science skills
• Diagnosing and treating people with mental disorders
• Putting in place strategies to prevent mental disorders
• Ensuring that primary health care workers are able to apply key psychosocial and behavioral science skills
For example:For example:
• Interviewing
• Counseling
• Interpersonal skills
• In their day to day work in order to improve overall health outcomes in primary care (WHO, 1990)
• Interviewing
• Counseling
• Interpersonal skills
• In their day to day work in order to improve overall health outcomes in primary care (WHO, 1990)
Integration of Behavioral Health in Primary CareIntegration of Behavioral Health in Primary Care
• Integrating specialized health services – such as mental health services – into PHC is one of WHO’s most fundamental health care recommendations (WHO, 2001)
• Integrating specialized health services – such as mental health services – into PHC is one of WHO’s most fundamental health care recommendations (WHO, 2001)
Rationale for Integrating Behavioral Health Services into PHCRationale for Integrating Behavioral Health Services into PHC• Reduced Stigma -
Patients are more comfortable in discussing mental health issues with PC provider
Because primary health care services are not associated with any specific health conditions, stigma is reduced
In general they have an established relationship with primary care provider because they are more inclined to follow up on medical care
“ I am not crazy “ less stigma walking into a PHC setting than a behavioral health setting
• Improved Access to Care Patients are more likely to keep appointments where multiple issues are being
addressed Better coordination of care
• Treatment of co-morbid physical conditions
• Reduced Stigma - Patients are more comfortable in discussing mental health issues with PC
provider Because primary health care services are not associated with any specific health
conditions, stigma is reduced In general they have an established relationship with primary care provider
because they are more inclined to follow up on medical care “ I am not crazy “ less stigma walking into a PHC setting than a behavioral health setting
• Improved Access to Care Patients are more likely to keep appointments where multiple issues are being
addressed Better coordination of care
• Treatment of co-morbid physical conditions
Co MorbidityCo Morbidity
• Behavioral health is often co-morbid with many physical health problems such as:
• Heart Disease
• HIV/AIDS
• Diabetes
• Tuberculosis
• Chronic Pain
• Behavioral health is often co-morbid with many physical health problems such as:
• Heart Disease
• HIV/AIDS
• Diabetes
• Tuberculosis
• Chronic Pain
Co MorbidityCo Morbidity
• When primary health care workers have received some behavioral health care training they can attend to the physical needs of people with behavioral health disorders as well as the behavioral health needs of those suffering from infectious and chronic diseases. This will lead to BETTER health outcomes
• When primary health care workers have received some behavioral health care training they can attend to the physical needs of people with behavioral health disorders as well as the behavioral health needs of those suffering from infectious and chronic diseases. This will lead to BETTER health outcomes
Morbidity and Mortality in People with Serious Mental IllnessMorbidity and Mortality in People with Serious Mental Illness
• Persons with serious mental illness (SMI) are dying 25 years earlier than the general population
• While suicide and injury account for about 30-40% of excess mortality, 60% of premature deaths in persons with schizophrenia are due to medical conditions such as cardiovascular, pulmonary and infectious diseases (NASMHPD, 2006)
• Persons with serious mental illness (SMI) are dying 25 years earlier than the general population
• While suicide and injury account for about 30-40% of excess mortality, 60% of premature deaths in persons with schizophrenia are due to medical conditions such as cardiovascular, pulmonary and infectious diseases (NASMHPD, 2006)
Improved Prevention and Detection of Behavioral DisordersImproved Prevention and Detection of Behavioral Disorders
• Primary health care workers are frontline formal health professionals
• First level of contact of individuals, the family and the community
• Equipping these workers with behavioral health skills promotes a more holistic approach to patient care and ensures both improved detection and prevention of behavioral disorders
• Primary health care workers are frontline formal health professionals
• First level of contact of individuals, the family and the community
• Equipping these workers with behavioral health skills promotes a more holistic approach to patient care and ensures both improved detection and prevention of behavioral disorders
Treatment and Follow –up of Behavioral HealthTreatment and Follow –up of Behavioral Health
• People who are diagnosed with a behavioral health disorder are often unable to access any treatment for their mental health problems
• Providing behavioral health services in a PHC, more people will be able to receive the services and care they need because:
• People who are diagnosed with a behavioral health disorder are often unable to access any treatment for their mental health problems
• Providing behavioral health services in a PHC, more people will be able to receive the services and care they need because:
Treatment and Follow –up of Behavioral HealthTreatment and Follow –up of Behavioral Health
• Better physical accessibility Primary health care is the first level of contact, usually
the closest and the easiest to access for individuals, the family and the community
• Better financial accessibility 340b program
• Better acceptability Linked to reduced stigma and easier communication
with health care providers
• Better physical accessibility Primary health care is the first level of contact, usually
the closest and the easiest to access for individuals, the family and the community
• Better financial accessibility 340b program
• Better acceptability Linked to reduced stigma and easier communication
with health care providers
Integrated Care Integrated Care
• Most effective approach to treat mental health in PC settings
• Comprehensive
• Multidisciplinary approach
• Fully integrated with information available to all practioners
• Cost-effective
• Most effective approach to treat mental health in PC settings
• Comprehensive
• Multidisciplinary approach
• Fully integrated with information available to all practioners
• Cost-effective
Challenges to Overcome for Successful IntegrationChallenges to Overcome for Successful Integration
• Integration of mental health services requires a lot of careful planning and there are likely to be several issues and challenges that will need to be addressed.
• Integration of mental health services requires a lot of careful planning and there are likely to be several issues and challenges that will need to be addressed.
For example :For example :
• Training of Staff
• Uncomfortable in dealing with mental disorders
• Overall reluctance of primary health care workers
• Availability of time
• Adequate supervision of primary care staff
• Human resource management issues-competencies
• Training of Staff
• Uncomfortable in dealing with mental disorders
• Overall reluctance of primary health care workers
• Availability of time
• Adequate supervision of primary care staff
• Human resource management issues-competencies
Clinical Barriers to Integrated CareClinical Barriers to Integrated Care
• Traditional separation of mental health issues from general medical issues
• Lack of awareness of mental health screening tools in the primary care setting
• Physician’s limited training in psychiatric disorders and their treatment
• Traditional separation of mental health issues from general medical issues
• Lack of awareness of mental health screening tools in the primary care setting
• Physician’s limited training in psychiatric disorders and their treatment
Financial BarriersFinancial Barriers
• Lack of insurance parity for psychiatric disorders
• Medicaid’s low reimbursement rates
• Billing restrictions
• Lack of insurance parity for psychiatric disorders
• Medicaid’s low reimbursement rates
• Billing restrictions
The following challenges are examples that policymakers should consider:The following challenges are examples that policymakers should consider:
1. Reimbursement for mental health services from Managed Behavioral Health Care Organizations
2. Reimbursement after an initial mental health screening or diagnosis
3. Limitations in reimbursement for non-physician providers, i.e case management
4. Limitations on billing for mental health services and an additional medical visit on same day
5. Coding and provider combinations that generate adequate reimbursements from Medicaid/Medicare
1. Reimbursement for mental health services from Managed Behavioral Health Care Organizations
2. Reimbursement after an initial mental health screening or diagnosis
3. Limitations in reimbursement for non-physician providers, i.e case management
4. Limitations on billing for mental health services and an additional medical visit on same day
5. Coding and provider combinations that generate adequate reimbursements from Medicaid/Medicare
Policy BarriersPolicy Barriers
• Health and Mental Health funding streams
• Difficulty in sharing information due to HIPPA regulations
• Health and Mental Health funding streams
• Difficulty in sharing information due to HIPPA regulations
Organizational BarriersOrganizational Barriers
• Shortage of mental health professionals
• Limited communication between medical and mental health providers
• Lack of agreement between medical and mental health provides
• Shortage of mental health professionals
• Limited communication between medical and mental health providers
• Lack of agreement between medical and mental health provides
Approach Description Benefits Limitations
Consultation Mental health experts are available by telephone or
video conferencing to provide consultation on medication management and in some cases direct mental health consultation to individuals
and families and referrals to local mental health specialist
Increases access to psychiatrists and other mental health specialists, particularly in underserved communities
with mental health workforce shortages; improves prescribing practices
Does not provide psychotherapy and evidence-based mental health
services
Co-location Primary care and mental health clinicians are
physically located in the same treatment setting. Mental health providers may be
independent practitioners or co-located in primary care but employed by mental health, or
other systems
Can reduce the wait for mental health services; may increase the likelihood that individuals and families will follow through with mental
health treatment
Co-location does not guarantee collaboration or an integrated
approach to practice
Collaborative and integrated models
Primary care practice has mental health clinicians on staffs that assess and treat individuals and families,
provide phone consultation to other systems, and facilitate case conferences. Integrated practice recognizes the link
between medical and mental health in every primary care
encounter and provides integrated care
A comprehensive approach that enables primary care to provide the full continuum of
services: screening, assessment, and treatment
Challenges include financial sustainability of mental health staff;
billing complexities
AtlantiCare’s JourneyAtlantiCare’s Journey
• Established 330h center in 2003
• Grant requires mental health and substance use services
• Psychiatric APN through NHSC until May 2009
• Introduced PhQ-9 to medical staff
• Established 330h center in 2003
• Grant requires mental health and substance use services
• Psychiatric APN through NHSC until May 2009
• Introduced PhQ-9 to medical staff
Co-location Co-location
• CIP grant dollars – satellite site
• MHC – AIS program
• Open July 2009
• CIP grant dollars – satellite site
• MHC – AIS program
• Open July 2009
Adult Intervention ServicesAtlantiCare Behavioral Health
Adult Intervention ServicesAtlantiCare Behavioral Health
A unique pilot program developed by Atlanticare
Behavioral Health to address the needs of the residents of
Atlantic CountyOne of two services of this
type in the state. Atlanticare Behavioral Health developed the program at the request of
the state.
A unique pilot program developed by Atlanticare
Behavioral Health to address the needs of the residents of
Atlantic CountyOne of two services of this
type in the state. Atlanticare Behavioral Health developed the program at the request of
the state.
PURPOSEPURPOSE
• To provide comprehensive short-term interventions to individuals who are experiencing significant and distressing symptoms due to mental illnesses
• To bridge the gap between the onset of acute symptoms and on-going treatment
• To reduce the number of mental health clients inappropriately treated in the ER
• To provide comprehensive short-term interventions to individuals who are experiencing significant and distressing symptoms due to mental illnesses
• To bridge the gap between the onset of acute symptoms and on-going treatment
• To reduce the number of mental health clients inappropriately treated in the ER
GOALS FOR EARLY INTERVENTION AND SUPPORT
SERVICES
GOALS FOR EARLY INTERVENTION AND SUPPORT
SERVICES• To provide accessible early and urgent
intervention, support services, and ongoing recovery supports to individuals, families, and consumers in acute distress
• To maintain or enhance the quality of life of the consumers and their families
• To provide community based crisis intervention through the development of a community walk in center and the provision of early intervention outreach services
• To provide accessible early and urgent intervention, support services, and ongoing recovery supports to individuals, families, and consumers in acute distress
• To maintain or enhance the quality of life of the consumers and their families
• To provide community based crisis intervention through the development of a community walk in center and the provision of early intervention outreach services
TARGET POPULATIONTARGET POPULATION
• Adults – 18 years of age or older
• Experiencing acute psychiatric symptoms
• Co-Occurring substance use disorders
• All of whom are in a community setting and can be safely stabilized, and subsequently provided ongoing individualized supports
• Adults – 18 years of age or older
• Experiencing acute psychiatric symptoms
• Co-Occurring substance use disorders
• All of whom are in a community setting and can be safely stabilized, and subsequently provided ongoing individualized supports
MHC-AIS Integrated ServicesMHC-AIS Integrated Services
• Monthly meetings established with Directors, medical and clinical staff and case management
• Weekly case management meetings between AIS-MHC to review progress on mutual patients and develop action plans for high risk patients
• Monthly meetings established with Directors, medical and clinical staff and case management
• Weekly case management meetings between AIS-MHC to review progress on mutual patients and develop action plans for high risk patients
Case Study-Billy E 61 year old African American male
Case Study-Billy E 61 year old African American male
Medical History• Diabetes,COPD,Hypertension,GERD, Glaucoma, Hepatitis C, Obesity,
Osteoarthritis, Asthma, Muscle weakness, Congestive heart failure
Psychiatric History• Major Depressive Disorder, Anhedonia,
past hx of alcohol abuse (5 yrs sober)
Medical History• Diabetes,COPD,Hypertension,GERD, Glaucoma, Hepatitis C, Obesity,
Osteoarthritis, Asthma, Muscle weakness, Congestive heart failure
Psychiatric History• Major Depressive Disorder, Anhedonia,
past hx of alcohol abuse (5 yrs sober)
Case studyCase study
• Patient of MHC since 2007
• Treated for medical and psychiatric issues
• May 2009 , psychiatric APN resigned
• APN referred Billy to behavioral health services
• Patient of MHC since 2007
• Treated for medical and psychiatric issues
• May 2009 , psychiatric APN resigned
• APN referred Billy to behavioral health services
Case studyCase study
• Billy does not follow through with behavioral health referrals
• Non-adherent to psychiatric medications and behavioral health services
• No follow through with appointments and specialty referrals (pulmonologist, nephrology, ID clinic)
• Decline in self esteem, feelings of hopelessness, lacks ability to function in social settings
• Difficulty trusting people• Isolating• Feels he has no one in his corner advocating for him
• Billy does not follow through with behavioral health referrals
• Non-adherent to psychiatric medications and behavioral health services
• No follow through with appointments and specialty referrals (pulmonologist, nephrology, ID clinic)
• Decline in self esteem, feelings of hopelessness, lacks ability to function in social settings
• Difficulty trusting people• Isolating• Feels he has no one in his corner advocating for him
Case studyCase study
• Encourage referral to AIS program
• co-located with MHC
• Intake and Psych evaluation on 3/10/2010
• Chief complaint- “I stopped taking my meds, ran out of them, I can’t sleep, I worry a lot, I can’t handle my stress. I feel depressed”
• Encourage referral to AIS program
• co-located with MHC
• Intake and Psych evaluation on 3/10/2010
• Chief complaint- “I stopped taking my meds, ran out of them, I can’t sleep, I worry a lot, I can’t handle my stress. I feel depressed”
Case studyCase study
• Billy accepted to the AIS program• Begins medication and treatment on 3/10/2010• Attends 5 groups per week, 1:1 counseling weekly, case
management services and medication monitoring• Follows through with 90% of appointments • Adherent to psych medication • Successfully follows through with specialty appointments• Involved in social functions – CODI, fashion show,
support groups, computer class• Increase in confidence and self esteem
• Billy accepted to the AIS program• Begins medication and treatment on 3/10/2010• Attends 5 groups per week, 1:1 counseling weekly, case
management services and medication monitoring• Follows through with 90% of appointments • Adherent to psych medication • Successfully follows through with specialty appointments• Involved in social functions – CODI, fashion show,
support groups, computer class• Increase in confidence and self esteem
Case studyCase study
• Remained with AIS for 2 months , discharged on 5/6/2010 and referred to ABH outpatient program
• Highest PhQ-9 score was 18
• Recent score 2
• Remained with AIS for 2 months , discharged on 5/6/2010 and referred to ABH outpatient program
• Highest PhQ-9 score was 18
• Recent score 2
Start your JourneyStart your Journey
